Several of us in the UCSF Division of Geriatrics have been talking recently about where clinician obligations ends and aspiration begins. This discussion raises important questions about the limits of professionalism.
The image is a conceptual model of this issue from a terrific paper by Gruen, Pearson, and Brennan.
Caring directly for the patient in front of you is clearly a professional obligation. In hospice care, this obligation theoretically extends to caring for the patient's family or loved ones. I have some concerns about balancing obligations to patients and their families, but let's leave that for another post. I think clinicians can agree that direct patient care is the core of our professional responsibility. Now let's move away from the center of the conceptual model.
The next layer in the model, providing access to care, is certainly a central issue in health care, and ought to be part of our professional obligation. This includes not just the usual health care coverage for all, but also access to interpreters for non-English speaking patients, accommodations for patients with disabilities, and mechanisms for serving rural and home-bound patients.
The layer out from this includes direct social determinants of health, like smoking. Counseling patients about smoking is a direct patient care issue, but advocating for local, state, and national laws to reduce smoking is a social determinant of health.
The outer two layers represent broader social determinants of health, such as income inequalities and racial/ethnic disparities, and global health issues such as the unequal distribution of resources and knowledge.
The further out from the center of the conceptual figure, the less direct the connection between that factor and health. While global health equity issues certainly contribute to international health disparities, the linkage is not as clear as, say, smoking and lung cancer. The clinician's responsibility to address these issues may be no different than any other citizen's responsibility.
Where do you draw the line between the obligations of health professionals in the public arena, and values that are worthy aspirations? Gruen drew the line between direct and broad social influences. I believe most health providers would draw the line between obligations and aspirations at the innermost circle - direct patient care.
Where should the line be?
by Alex Smith
7 comments:
What a wonderful, thought-provoking post! I think about this issue frequently in connection with climate change, which will have a significant impact on health. I figure since this impact is something the medical profession can understand and appreciate, physicians should do their part in educating the public, even if that only takes the form of writing an occasional New York Times editorial. But I don’t see this happening. (I’m not aware of blogging doctors who write about the health consequences of climate change and would love to learn of some.)
Now I understand. As you say, it’s likely that most health providers (in the US, anyway) limit their concerns to direct patient care.
I’m continually struck by the difference between British and American medical journals when it comes to discussing global health issues. There are frequent articles in British journals and very few in American ones. I can understand that some of this is a legacy of the British Empire. But with climate change, health will be affected in the southern US. Perhaps it’s the same Empire explanation, however, since the poorest countries will be affected first.
The question of responsibility also touches on British/European/Canadian/Japanese approaches to universal health care as opposed to the history of health care in America. As French President Sarkozy said when our recent health care bill passed: “Welcome to the club of states who don’t turn their back on the sick and the poor.” One might argue that this is a political issue, but American doctors are a product of American culture.
This is a complex subject, I realize, but what a fascinating one. Thanks so much for bringing it up!
Check out the "On Being A Doctor" essay "Final Visit" in this week's Annals. The question is moot. Most primary care clinicians don't have the time to do anything but see patients and struggle through their paperwork (if even that).
Jan - thanks for your comment. This doesn't necessarily have to be political. It's only political in that many of the social programs that would address non-biological determinants of disease are supported by the democrats primarily, but not at all exlusively (hand gun control, anti-smoking, expanding access to health care).
That was a great article, anon, thank you for pointing it out. It is hard for primary care doctors to focus on anything "upstream" when they are drowning in patient care. It's just "one more thing" they can't get to at the end of the day.
But this isn't just about primary care doctors - it's also about the responsibility of radiologists, ophthomologists, anesthesiologists, dermatologists, and non-physician health care providers. Becuase primary care doctors are most impacted and "see" more of the effects of the social determinants of disease, they "feel" more of an obglication to act. But doesn't the health profession as a whole have an obligation?
Perhaps the societal and political perspectives on Dr. Smith's questions are separate from the individual doctor's perspective. That is, there are many practical constraints and personal limitations that might affect what is one's "obligation" vs. "aspiration." Doctors are human (gasp), and each doctor has to determine how many layers out they can devote. The "aspiration" can be defined as covering as many layers out as possible, while the obligation is to always do the best that you can within whatever layer you are currently in. There is a tipping point at which extending one's self too broadly (prompted by a worthy aspiration), interferes with the fullfillment of one's obligations. I.e., better not to sign up to lead the Public Healthcare Rally if you are already struggling to meet the needs of your current patient panel. This goes for any doctor.
From a utilitarian perspective, we also have an obligation to operate in the layer where are strengths can have the biggest impact; i.e. are you a better one-on-one in the clinic, or leading groups of educated individuals for social change, etc. Moral responsibility is inherently very subjective. Lastly, I believe that there is a conflict between the historic notion of a doctor's role as a "healer," with the reality of what we really are . . . as evidence-based medicine becomes more prominent, we are more and more aware of the limitations of our own medical practice.
As much as we want our goal to be to do as much as we can for health at every layer, we have a long way to go before we are even adequately performing at the doctor-patient layer. If the strongest determinants of health truly are outside of the direct doctor-patient interaction, maybe it is more about replacing, as opposed to expanding, our current obligations.
One of my mentors uses this figure when he lectures on advocacy. Alex, I'm not quite sure what the answer to your question is as I think more advocacy would be important but I'm not sure what to give up.
Regarding the utilitarian comment from anonymous, he does use the example of helping to write the Colorado tobacco tax law and he stated that this will help (using data from other states that more expensive cigs lead to less people starting) more people than all of the patients he sees.
Alex, do you count this blog as your advocacy?
Thanks Anon for your thoughtful comments. I particularly agree with your observation that individuals should play to their strengths - if someone can do the most good by focusing on public policy issues, that should be their focus, if they can do the most good in the doctor-patient relationship, that should be their focus.
But primary individual focus does not obsolve the profesional field from the moral responsibility of providing care that improves the health of patients. I believe this professional responsibility includes the social determinants of heatlh.
Dan, thanks for your comments. You're right about trade-offs. As anon said, we should each play to our strengths, and individuals need to prioritize obligations outside of the profession - like family. I do count blogging at GeriPal as a contribution to toward my public role (as should you!)
I believe that each clinician must draw an individual line of obligation. We certainly have those within our own "job" to care for, but then, deep in many hearts is also the "obligation" to share what we know with global communities. Teaching physicians in Copan, Honduras, Russia, and China is the heart's desire of one of our pediatric hospitalists who started out with a team I was a part of to set up a clinic that would be in existence long after we went back home. Having taught others what to do allowed them to serve the poor there, even with their limited pharmacy. When empowering the physicians and nurses in those areas, then it is up to them to do the political work of getting opioids and other medicines to help their people. And in many countries, the clinicians have influence. Medical brigades serve a temporary service, but not a long lasting one.
Education is the key to empowerment. Remember when Iraq was liberated? Our physicians who served there asked for current medical books and journals because now there was freedom to learn and more than a small amount of eager learners! And those who have been to some of these places know that the people who live there never leave our hearts and minds as we enjoy our standard of living here in this great country.
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